1. Field of the Invention
This invention generally relates to the field of computer-based documentation systems. Specifically, the invention relates to systems used for medical documentation of medical records and recovery of payments. Additionally, the invention is used in non-medical areas, such as automotive repair, legal services, and other service oriented businesses where records are kept as criteria for goals such as compensation.
2. Description of Related Art
Current documentation systems exist in all areas of businesses and services. These documentation systems have been improved through digital methods and the implementation of computers. There are however, numerous problems arising with documentation systems that include, but are not limited to legibility, clarity, completeness, and accuracy of documenting data.
Particularly in the medical field, clear, accurate, and complete documentation of patient encounters with health care providers is crucial for proper patient care and payment reimbursement by third party payers. In fact, improper patient care occurs due to the inability of health care providers to read unclear and incomplete documented notes. Frequently, medical histories, physical findings, diagnosis and subsequent treatment are lacking in detail within the documentation of the patient's encounter with the health care provider. Additionally, the true severity of the patient's illness is not accurately reflected in the documentation of the patient's encounter. Thus, incomplete diagnosis, which leads to misleading treatment and improper reimbursement, occurs.
In addition to problems with patient care, payment reimbursement based on medical codes and documentation is incomplete and not properly provided. The documentation of the patient encounters must be done in a proper format and include certain criteria. The criteria or information regarding the patient encounter must accurately describe the medical history, diagnosis, assessment of problems, and treatment performed on the patient. Many times, the criteria or information entered regarding the patient encounter are misleading or incomplete for medical coding. As a result, satisfying government and insurance regulations is very difficult and receiving the appropriate level of payment does not occur.
The current medical reimbursement payment system utilizes physician Evaluation and Management CPT-4 Codes (E&M CPT-4 Codes) that relate to physician and hospital revenue. Third party payers, such as the Health Care Finance Administration (HCFA) who oversees the Medicare program, are responsible for payment reimbursement. Hospitals and other health care providers are under government scrutiny because of the known inaccuracies and potential fraud occurring in assigning E&M CPT-4 Codes in relation to the services rendered by health care providers. E&M CPT-4 Codes are assigned and correlate to the medical treatment and service rendered to the patient by the health care provider. Assignment of the E&M CPT-4 Codes directly depends upon the documentation made by the health care provider. The E&M CPT-4 Codes are used for defining the reimbursement levels for the health care provider's services.
The terminology and detail of documentation for certain diagnoses are frequently incomplete with regard to the requirements for proper payment reimbursement. In order to receive the appropriate level of payment reimbursement, the proper medical billing codes must be assigned to the services rendered by the health care provider. In turn, proper medical billing codes will determine the level of reimbursement. The description of the appropriate services rendered is crucial in ultimately determining payment reimbursement. Therefore, accurate and complete documentation of the patient encounter must meet certain criteria in order to be assigned to the appropriate medical billing code.
Third party payers, such as HCFA, use a classification method known as Diagnosis Related Groups (DRG) to reimburse hospitals for inpatient care. The classifications are defined by the patient's diagnoses and procedures performed on them. Each DRG classification assigns a fixed, resource consumption to a particular illness as measured by the length of stay and cost.
Most third party payers have adopted criteria for admitting patients to an acute care hospital as well as for indicating which patients should undergo certain procedures. Frequently, documentation by the physician does not address all the details of the history and physical for a particular patient; therefore, key elements are missing that would otherwise support the need for a patient to be admitted or to undergo the procedure. Therefore, reimbursement rates are not appropriate, or an actual denial occurs from the third party payer.
Although current systems exist to aid medical documentation, there is a need for improvement. Current systems used in other fields have greatly improved documentation. There are many programs and applications existing that assist the individual in documenting information by providing prompting functions. For instance, the Turbo Tax program has a prompting feature that asks questions based on previous questions. Therefore, answering questions in one manner leads to another question that will elicit more detailed information. In the Turbo Tax program, the first question asks whether or not the individual has W-2 income. If the individual answers “yes,” the program asks the individual to then provide pertinent data for a W-2. There are other programs such as Microsoft Excel that utilize formulas that prompt the user with a message if the user makes a mistake with the formula. The software prompts the user with the option to view the location of the mistake. If the user chooses to view the mistake, help comes up on the screen with the information to correct the error.
In the medical field, the medical documentation systems currently on the market are directed to outpatient documentation only. Some systems are geared toward extended care facilities and others toward creating complete electronic medical records. There are no systems that possess a processing mechanism that assists in the completing of patient records to augment the medical coding in both the outpatient and inpatient settings.
Accordingly, in response to the documentation systems currently existing, there is a need for a system that provides more complete, accurate, accessible and legible documentation of the health care provider component of the medical record. Further, there is a need for a system that elicits more accurate conclusions through the analysis of entered information and predetermined criteria input. Finally, there is a need for a system to augment the medical coding in the inpatient setting to obtain accurate DRG-based reimbursement.